Nidal knew that the ambient conditions had to be just right for the release of his weapon, to maximize dispersion and ensure the greatest exposure among his targeted population. As he prepared the weapon for employment, he considered how perfectly the timing of the 1941 attack played into his devious intentions. For better than ten months of the year, the Hawaiian Islands enjoyed the flow of warm trade winds from the north, but December normally brought in the wetter and slower Kona Winds, which flowed from the south. With a slower and less turbulent breeze, and a higher degree of humidity, the heavy, wet air was perfect for the dispersion of an organic agent. Nidal knew that it virtually guaranteed that his silent and deadly weapon would fall within the projected dispersion area on Oahu, rather than being carried beyond the targeted location to fall uselessly into the open sea.
As dawn approached, Nidal moved quickly to execute the final stages of the plan. After retrieving the weapon from the vehicle, the terrorist made his way forward to the forecastle of the ship, and positioned himself at the hawsehole of the anchor to prepare the dispersion. His scientists—two itinerant microbiologists who had worked for the Soviet Union's biological weapons program and had been lured to Nidal's organization with promises of significant monetary incentives—had loaded 50 kilograms of dried anthrax into a single, well-wrapped, and compressed package.
Nidal had no fear of the biological agent. He and his operatives had obtained anthrax immunizations from the British and the Americans—two of the only three countries producing a chemoprophylactic vaccine against exposure to weaponized inhalational anthrax. To enhance his chances for survival, Nidal had taken the full series of each of the immunization protocols. In addition, because the agent's mechanism of infection was through inhalation, he simply donned a respirator a moment before he sliced open the wrapper of the package. Unlike his countrymen who died as a result of their commitment to the Jihad, Nidal had no desire to become a martyr. He wanted to be around to relish the suffering of the nation he believed had caused so much pain and death to the innocent women and children of his land.
The dispersion mechanism was ludicrously simple, and Nidal laughed quietly as he thought of the billions of dollars that had been spent by the world's superpowers to charge their weapons programs. The wealth of nations wasted, he thought; the most powerful country in the world was about to be brought to its knees by one man with a few hundred dollars worth of equipment—and one of the most deadly organic agents known to man. Nidal had obtained a portable air blower—the kind used by housepainters to help dry freshly painted walls. At the blower's business end, he had attached a flexible hose about 12 inches in diameter. He placed the end of the hose through the anchor's hawsehole, so that it just barely protruded outside the ship's hull. At the intake end, Nidal attached another hose, which would act like a vacuum to suck the deadly pathogen through the whirring fans and out into the open air. The anthrax attack on Oahu required no more than a steady stream of air to launch.
With a final look at his watch, and a mumbled prayer to Allah, Nidal placed the intake hose into the opened package of anthrax and flicked the switch on the blower. It was exactly 0758—58 years to the minute after the first attack on Pearl Harbor. This time, however, there were no sounds of attacking Zeros, no whoosh of exploding bombs—not even the blinding flash of nuclear fission. The only sound was the soft hum of a housepainter's blower, lost in the lapping of the Pacific waves against the hull. From two miles out at sea the microscopic anthrax spores were lifted gently onto the prevailing wind. As the people of Oahu began their day, the deadly bacteria floated languidly toward the island.
The first symptoms of inhalational anthrax begin anywhere from 24 hours to six days after exposure, and usually feature fever, malaise, and fatigue. A nonproductive cough and a vague sense of chest discomfort may be present. This early phase of the disease may be followed by a spontaneous symptomatic improvement—or it may progress directly to the abrupt onset of severe respiratory distress, with dyspnea (difficult or labored breathing), stridor (a high-pitched respiratory sound often heard in laryngeal obstruction), diaphoresis (profuse perspiration), and cyanosis (bluish skin associated with lack of oxygen in the blood). Bacteremia (bacteria in the blood), septic shock, metastatic infection (widespread infection; including meningitis in approximately half the cases), and death usually follow within 24 to 36 hours. In laymen's terms, after inhalation, the anthrax spores are carried to the lymph nodes in the tissues and organs separating the lungs (the mediastinum), where they begin to vegetate and release toxins. The toxins result in swollen, bleeding lymph nodes and cause fluid to accumulate in the mediastinal space late in the disease, causing the characteristic widening of the mediastinum on a chest X-ray. The spread of toxins causes significant swelling and cellular decay, with subsequent shock and death. Unless there has been prior immunization, once symptoms appear, treatment invariably is ineffective, although there are anecdotal reports of patients surviving after very early confirmation of exposure and extremely aggressive antibiotic and supportive therapy. 1
Epidemiologists consider it a necessity to locate the "index case," or "patient zero," when tracking the outbreak of a significant disease event. In this outbreak, the index case (which would never be discovered) occurred in a young housewife and mother who lived in Navy housing at Hospital Point, at the mouth of the entrance to Pearl Harbor. The wife of a Navy commander who skippered a destroyer, she contracted the illness when she opened the door of her home and breathed in the deadly spores while bending down to kiss her children good-bye on their way to school. Her children—a boy and two girls ranging in age from 6 to 11—received a lethal dose of the agent milliseconds behind their mother, as they ran off to their bus stop. They all would be dead within 72 hours. The cloud of dispersed anthrax had reached landfall, and within hours would begin infecting a staggering number of people.
The first cases began making presentations to local medical facilities early the next morning. Their symptoms began just over 24 hours after Mustafa bin Nidal muttered his silent prayer, and nearly 20 hours after he had boarded a plane bound for Korea, and eventually back to his home in Iraq. He would never be implicated in this unprecedented crime. At first, it was perplexing—and slightly worrisome—to the overwhelmed healthcare providers that so many people were reporting to their hospitals and clinics with nearly the same clinical presentations: low-grade fever, tiredness and body ache, and some with minor breathing difficulty. Suspecting an outbreak of some influenza-type illness, they sent home nearly 100% of the cases reported that day with a prescription for rest, plenty of fluids, and analgesic therapy, as needed to relieve their pain and make them more comfortable.
By late afternoon, however—now approaching 36 hours after the dispersion—the situation turned dramatically worse, and it became apparent that Oahu was rapidly approaching a true public health emergency. Because of its location between Asia and the United States, and because of the constant flow of international tourists and business travelers through Hawaii, local public health officials had long been wary of and keenly alert to the potential for a significant disease outbreak among the islands. The steps to assess and to develop a plan to counter or mitigate the effects of a widespread outbreak had been painstakingly developed over the years, but it took only moments for the medical and public health communities to realize that what they were seeing went far beyond any notion of a worst-case scenario.
The dispersion plume had laid down a swath of the deadly agent throughout central Oahu. If it were possible to view the island on a three-dimensional plane, the south-central part of Oahu would appear as a giant, half-sided bowl, trapping the anthrax for maximum effect against the targeted population. Within 15 hours of Nidal's silent act of terrorism, the anthrax spores had fallen like an invisible blanket over the main part of the island. Starting with Pearl Harbor and spreading as far east as Diamond Head and as far west as Barber's Point, the anthrax had reached nearly 98% of the population center of Hawaii's busiest and most densely populated island. The scene by late evening had become nightmarish, as sick and dying patients crowded around every available medical facility. Those who could not make it to a medical facility remained at home, in mounting panic as their symptoms worsened. Others, giving in to what was by now raging fear, had attempted to seek some sort of help before their conditions worsened, and had created the most monumental traffic jam Oahu had ever seen.
Not surprisingly, Oahu's significant military population remained largely asymptomatic, because of the Department of Defense's 1997 decision to begin immunizing the active-duty component in the face of a mounting global bio-warfare threat. By the second morning after the attack (D+48 hours), when dying patients began to display some of the symptoms associated with the final stages of a terminal exposure, physicians at Tripler Army Medical Center put two and two together, and realized that they were dealing with a massive exposure to weaponized inhalational anthrax. Despite this realization, there was little anyone could do. At best, patients who had only just begun to show symptoms could be treated with IV antibiotics, in the faint hopes of curing the disease. Those who had yet to show any symptoms could be given oral anitbiotics and the anthrax vaccine, in hopes of stalling the effects and building a resistance to the agent. Even these efforts became moot, however, when stocks of available drugs quickly dwindled in the face of such an enormous number of casualties. The best the medical community could do was provide palliative therapy for those people lucky enough to make it to a hospital, trying to make them as comfortable as possible as they progressed rapidly toward death.
The phenomenon of real-time media reporting only worsened this terrible event. As the survivors of the attack managed to access the state's radio and television stations, and word of the events in Hawaii reached Washington and the rest of the nation, widespread panic ensued. Surely, if "they" could strike Hawaii, many thought, there was nothing to keep them from the major coastal cities and other high-value military and civilian targets throughout the country. Beyond the death and suffering endured by the citizens of Oahu, the psychological impact on the nation was unfathomable. Americans were pitched into an icy fear that they would be struck next by this invisible killer. Neither the calming voice of the President nor placing the military on its highest defensive posture could assuage the dread that every American now would forever be forced to live with.
The attack was successful beyond the wildest dreams of Nidal and his terrorist sponsors. The initial dispersion could be neither seen, smelled, nor heard, so there was never any concern regarding detection or the mounting of defensive measures by the U.S. government. The enemies of the United States had long recognized the severe limitations of biodetection capabilities, and had capitalized on this poor level of preparedness to strike a crushing physical and psychological blow. Even though the head of the Iraqi government had himself supported and sponsored the employment of a biological weapon, the United States' inability to determine the source of the attack provided the Iraqis plausible deniability. This effectively negated the U.S. declaratory policy that governments sponsoring or supporting the use of weapons of mass destruction would face the unbridled wrath of the world's sole superpower. For the second time in history, the nation had been emasculated. But unlike the Japanese attack on Pearl Harbor in 1941, this date of infamy had no one with whom the Americans could definitively place the blame—except, perhaps, themselves, for failing to adequately prepare the nation for this darkest of moments.
In the end, the world's first use of a weaponized biological agent against a large human population resulted in a staggering loss of life. Of the nearly 836,000 residents of Oahu, approximately 500,000 received direct exposure to the anthrax dispersion, based on plume dispersion models against the known population concentration. More than 220,000 people died. 2 Because Bacillus Anthracis can live in the soil for more than 50 years and reaerosolize and reinfect individuals who disturb the ground spores, Oahu became uninhabitable. Like the Scottish island of Gruinard, where the British had tested weaponized anthrax nearly 60 years earlier, Oahu became a dead zone, considered unsafe for future human habitation. 3
The noise of the fourteen thousand aeroplanes advancing in open order. But in the Kurfurstendamnn and the Eighth Arrondissement, the Explosion of anthrax bombs is hardly louder than the popping of a paper bag.
Aldous Huxley, Brave New World (1932)
A critic of Aldous Huxley once noted with the smug certainty of a contemporary that "one vast and obvious failure of foresight is immediately apparent (in that) Brave New World contains no reference to nuclear fission." 4 It is interesting to note, however, that Huxley's prognostications in 1932 did foresee the use of biological weapons. Perhaps he was far more visionary than anyone has given him credit for. With the demise of the Soviet Union—our former malefactor-partner in the concept of mutually assured destruction—the threat of nuclear Armageddon virtually has been eliminated, but as many of the leading minds of science, politics, and the military have said, the new "threat du jour" is the weaponized bio-agent. Perhaps we have come full circle, back to Huxley's predictions of the future world.
Recently, a number of interesting and informative articles have pointed out that the use of biological weapons is not new. 5 Indeed, some leading authorities on the subject have theorized that the Great Plague of the 14th century may have resulted from the offensive use of a pathogenic agent. 6 If this theory has merit, the casualties of Hiroshima and Nagasaki would pale in comparison to the number of casualties generated by the weaponized use of an organic agent. 7 Why should we fear the proliferation of weaponized pathogens? The potential for destruction among the human population is simply enormous.
The fictionalized account of a second catastrophic attack on Pearl Harbor illustrates a number of significant points relative to the threat of bio-weapons and our current state of preparedness in the face of that threat. Because the term consequence management (CM) has become such a routine part of the lexicon used to describe how we would cope with such an event, it is essential to take a hard look at the institution that ultimately will be responsible for picking up the pieces—medical support.
It is hard for anyone to conceive just how bad the outcome of a massive biological exposure would be, as there is nothing in recent memory with which to compare it. Sustaining casualties that could run into the hundreds of thousands staggers the imagination, and promotes a nearly reflexive response to ignore it, and hope it will go away. But the reality is that we must plan for this eventuality, and significant quantitative analysis must be conducted to ensure that sufficient health service support (HSS) is available to meet requirements. At present, however, that is impossible, as there are neither good predictive planning factors nor the capability to model HSS requirements accurately in a biological (or nuclear and chemical) contaminated environment. Part of the problem lies in the fact that there are no historical data from which to develop planning factors, factors that in turn would be used to develop casualty stream algorithms. The sole DoD-approved predictive requirements generator and course-of-action analysis model, the Medical Analysis Tool (MAT), could generate requirements in the weapons-of-mass-destruction (WMD) environment if such factors were available. A number of systems exist to model plume dispersions associated with WMD events, and to factor in such variables as type of agent, ambient weather conditions, terrain, and structural obstacles, but none has yet demonstrated an interface with a system that models effects against an established population at risk, the baseline of assessment when determining requirements for HSS in the operational environment. 8 This leaves a critical shortfall in the medical planning community.
In the event of a suspected biological attack, our ability to identify, diagnose, or even determine that the event has indeed taken place is problematic. In the military, unified commanders today rely on one of several units and/or deployable capabilities when the use of a biological agent is suspected:
The U.S. Army Medical Research Institute of Infectious Disease (USAMRIID), considered to be the national asset in responding to biological WMD events
The Naval Medical Research Center (NMRC)
The U.S. Army's Theater Army Medical Laboratory (TAML)
- The Naval Medical Research Units (NMRUs) and Environmental and Preventive Medicine Units (EPMUs)
The problem with these units has nothing to do with their capabilities; they have some of the best trained and equipped staffs in the world. Rather, the problem lies in the "tyranny of distance" concept: when a biological event is suspected, these units have to be notified, prepared for deployment, and transported—often great distances—before they can begin their assessments. In addition, most require large logistical efforts to move sufficient personnel and equipment to the site of a suspected event (for example, the TAML requires 138 flatbed trucks or 18% of a roll-on/roll-off cargo ship to move unit supply sets). The Department of the Navy is in the process of fielding a Forward Deployable Preventive Medicine Unit (FDPMU) specifically designed to provide a rapid response to suspected WMD sites, but we still are at least two years away from having an active asset available for employment by the geographic commanders-in-chief.
Our ability to detect the presence of chemical agents is considered strong; unfortunately, the capability to detect and confirm the employment of a biological agent from either a stand-off or remote source is nonexistent. Detection systems for biological agents are triggered by changes in ambient particulate matter. Once the alarm sounds, technicians still are required to remove the micron filtration devices and conduct laboratory assays to determine whether a pathogenic agent has been dispersed. This is a time-consuming and laborious process, and during this diagnostic phase, possible exposure in the targeted human population may be occurring. Multivalent or omnivalent detection capability against known weaponized pathogenic agents have been functional in laboratories for years (such as the tiny-time-of-flight mass spectrometer), but they still are some time away from being fielded effectively. 9 The ability to conduct confirmatory testing is of equal concern. A false-positive or a false-negative identification of a bio-agent used against U.S. personnel would have serious consequences and potentially strategic geopolitical implications.
DoD's anthrax vaccine immunization program was an enormous step toward coming to grips with the threat of biological weapons, and toward providing substantive health protection measures for our military forces. Because of its lethality, ease of weaponization, and persistence, anthrax is one of the most worrisome bio-agents known to have been weaponized by rogue nations and extremist factions. Most weaponized pathogens have either FDA-approved vaccines or vaccines that are designated as "investigational new drugs" (which, under current law, can be used by DoD when force protection measures require). There is, however, a new class of potential agents that merits our attention: recombinant and midspectrum (or advanced biochemical) agents. Recombinant and genetic engineering technology could allow scientists to develop agents, such as modified viruses, that will exacerbate existent difficulties in detection and diagnosis, and defeat current chemoprophylactic and treatment protocols. New classes of agents, known to be in laboratory development, do not fit into the traditional categories of biological agents. Several countries already have the potential to develop new classes of biological threats based on these types of technology. 10
Finally, it must be recognized that medical consequence management of a biological-weapon-of-mass-destruction event will be problematic, as intense casualty streams will be likely to overwhelm available medical resources in short order. The medical assets of the U.S. national inventory are ill prepared to deal with patients exposed to these agents. The most that could be hoped for would be reliance on nearby medical support facilities, but these either will be immediately overwhelmed or will suffer from the same physical degradation as all other emergency response infrastructure.
The possibility of seeing a biological agent used as a weapon of mass destruction seems to increase daily. In a recent interview, President Bill Clinton went so far as to warn of the likelihood of a biological WMD attack against the continental United States within the next few years. 11 So, how do we contend with these significant issues, and attempt to manage this significant threat?
First, we need to develop joint nuclear/biological/chemical planning factors to predict requirements in the WMD environment, and adjust current predictive requirements modeling systems (such as the MAT) to accommodate the use of these agents against U.S. forces or population centers. That is the only way that medical planners can quantitatively and qualitatively assess requirements for this environment. It is not enough to speculate, or to add hypothetical figures to conventional requirements, to determine the adequacy of health service support in a bio-scenario. If we are to have sufficient assets to support a bio-event, the same scientific rigor for analysis of requirements conducted in the symmetrical environment must be available to unified command medical planners when planning against asymmetrical threats.
Second, we need to emphasize the development, expansion, and expeditious fielding of rapidly deployable theater medical assets. The specific mission of these units should be the identification of WMD agents in a potentially contaminated bio-agent environment (to include up to a bio-safety level IV capability). It is not enough for the combatant commanders to rely on such currently deployable units as the U.S. Army Medical Research Institute of Infectious Disease or the Theater Army Medical Laboratories—not because they lack competent capabilities, but because they will take too long to get there. The geographic commanders-in-chief should have their own cadre of scientists available to deploy in the same fashion as the deployable joint task force augmentation cells (DJTFACs). In the same vein, they should consider the development of regional chemical and biological augmentation response teams, which would be comprised of a select group of medical professionals (clinicians, planners, medical intelligence specialists, logisticians, and communicators) skilled in medical consequence management and capable of tying together the medical and emergency response assets of a wide geographic region.
Third, it is imperative that we accelerate the research and fielding of multivalent or omnivalent stand-off point detection systems that will alarm on detection of weaponized pathogenic agents, provide real-time and accurate identification of the pathogen, and allow sufficient time for targeted populations to assume a protective posture against lethal exposure.
Fourth, reliance on individual vaccines for protection against each individual agent is worrisome, especially given recent advances in recombinant and bio-engineering technology. Although many in the scientific community have argued that omnivalent vaccines are the stuff of science fiction, at a minimum, the Defense Scientific Community must aggressively pursue chemoprophylactic measures that can provide protection against the multivalent threat of a recombinant or midspectrum bio-agent.
Fifth, although we must recognize and accept that the dispersion of a bio-weapon likely will overwhelm available medical resources in a potentially wide geographic area, DoD should consider tasking the services with the development of large-scale deployable medical system platforms that are capable of handling biologically con-taminated patients (perhaps communicable, as well) and the intense casualty streams in an affected population.
Passive response equates to danger in the asymmetrical threat environment. If we have accepted—as the President has—that the likelihood of encountering a bio-attack has increased exponentially, then we must move out aggressively to counter that threat and ensure that our consequence management capabilities are optimized. Prior to the strike on Pearl Harbor, most Americans believed that such an attack against the United States was beyond plausibility. If we ever see a U.S. population attacked by a biological agent, the "Date that will live in Infamy" will pale in comparison. It is best that we prepare.
Commander Marghella, a 1998 graduate of the College of Naval Command and Staff, is medical plans officer and special advisor for the medical effects of weapons of mass destruction on the staff of Commander-in-Chief, U.S. Pacific Command. He wishes to thank the following individuals for their assistance in preparing this article: Zenaida Marghella, Captain Bill Frank (PacFleet), Jan Herman (BuMed), Steve Greco (J-5/WMD, CinCPac), Commander Randy Culpepper (USAMRIID), Lieutenant Commander Stew Smith (Joint Staff), and Lieutenant Commander Mike Vineyard (PacFleet).
1. D. R. Franz et al., "Clinical Recognition and Management of Patients Exposed to Biological Warfare Agents," Journal of the American Medical Association 278, no. 5 (6 August 1997): p. 399. back to article
2. WHO Group of Consultants, Health Aspects of Chemical and Biological Weapons (Geneva: World Health Organizations, 1970). The "WHO Estimate of Casualties Produced by Hypothetical Attack" cites figures of "95,000 dead and 125,000 incapacitated" as a result of the "release of 50 kg of agent (anthrax) by aircraft along a 2-km line upwind of a population center of 500,000." There are, however, conflicting statements regarding the level of lethality of weaponized inhalational anthrax. DoD generally cites a projected 99% lethality in an exposed, nonprotected population (DoD, Report on the Conduct of the Persian Gulf War [Washington: 1992], chapter 1, p. 15). The only real-world exposure to weapons-grade inhalational anthrax occurred in Sverdlovsk (now Ekaterinburg, Russia) in April 1979; 66 deaths occurred among 77 confirmed cases among people living within four kilometers of a verified bio-weapons production facility. It is not known how much anthrax was released from the facility to cause the deaths. For the purposes of this article, the death toll was raised approximately 20% above the estimates provided by the WHO. back to article
3. Robert Harris and Jeremy Paxman, A Higher Form of Killing (New York: Hill and Wang, 1982). back to article
4. Foreword to Brave New World , by Aldous Huxley (New York: Harper and Rowe, 1969), p. ix. back to article
5. G. W. Christopher et al., "Biological Warfare: A Historical Perspective," Journal of the American Medical Association 278, no. 5 (6 August 1997): p. 412; and R. Danzig and P. B. Berkowski, "Why Should We Be Concerned about Biological Warfare?" J ournal of the American Medical Association 278, no. 5 (6 August 1997): p. 431. back to article
6. Christopher et al., "Biological Warfare," p. 412. back to article
7. It is estimated that the Black Plague of 1347-1351 was responsible for more than 25 million deaths in Europe alone. In comparison, the casualties of Hiroshima and Nagasaki were 140,000 and 225,000, respectively. back to article
8. As an example, the Defense Threat Reduction Agency has developed the "Hazard Prediction and Assessment Capability" (version 3.1) computer software for modeling dispersion effects of chem-bio WMD. back to article
9. Jessica Drake, "After All These Years: Chem-Bio Defense Unequal to Threat," National Defense , December 1998, p. 39. back to article
10. "Report on Chemical and Biological Weapons Proliferation Control Efforts," Report Submitted to the Congress Pursuant to Section 308 of the Chemical and Biological Weapons Control and Warfare Elimination Act of 1991, Public Law 102-182, 1 February 1998 to 31 January 1999; and Richard Preston, "Annals of Warfare: The Bioweaponeers," The New Yorker , 9 March 1998, pp. 52-65. back to article
11. J. Miller and W. J. Broad, "Clinton Describes Terrorism Threat for 21st Century," The New York Times , 22 January 1999, p. 1. back to article